Texas 2013 - 83rd Regular

Texas House Bill HB1406 Compare Versions

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1	1	83R3617 AJA-D
2	2	By: Smithee, Bonnen of Galveston H.B. No. 1406
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the disclosure of the calculation of out-of-network
8	8	payments by the issuers of preferred provider benefit plans and by
9	9	health maintenance organizations.
10	10	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11	11	SECTION 1. Subchapter F, Chapter 843, Insurance Code, is
12	12	amended by adding Section 843.212 to read as follows:
13	13	Sec. 843.212. CALCULATION OF NONPARTICIPATING PROVIDER
14	14	PAYMENTS. (a) In this section, "usual charge for out-of-network
15	15	health care services" means the 99th percentile of the actual
16	16	charges charged by a physician or provider that does not
17	17	participate in a health maintenance organization's delivery
18	18	network for a particular health care service in a particular
19	19	service area covered by the delivery network, as reported in a
20	20	benchmarking database maintained by a nonprofit organization that
21	21	is not affiliated with a health maintenance organization or other
22	22	health benefit plan issuer, a holding company of a health benefit
23	23	plan issuer, or a trade association in the field of insurance or
24	24	health benefits.
25	25	(b) A health maintenance organization shall disclose to
26	26	each enrollee and, if applicable, each group contract holder the
27	27	methodology used by the health maintenance organization to
28	28	calculate payment under the health plan for health care services
29	29	provided by a physician or provider that does not participate in the
30	30	health maintenance organization's delivery network. The
31	31	disclosure required by this section must:
32	32	(1) express the payment amount in terms of a
33	33	percentage of the usual charge for out-of-network health care
34	34	services that will be paid to the physician or provider; and
35	35	(2) include examples of the anticipated out-of-pocket
36	36	payment responsibility for frequently billed health care services
37	37	provided by physicians or providers that do not participate in the
38	38	health maintenance organization's delivery network.
39	39	(c) A health maintenance organization shall, at the request
40	40	of an enrollee, provide the enrollee with information, in writing
41	41	or through publication on an Internet website, that allows the
42	42	enrollee to determine the anticipated out-of-pocket payment
43	43	responsibility for a specific health care service provided by a
44	44	physician or provider that does not participate in the health
45	45	maintenance organization's delivery network based on:
46	46	(1) the methodology used by the health maintenance
47	47	organization to calculate payment under the health plan for health
48	48	care services provided by physicians and providers that do not
49	49	participate in the health maintenance organization's delivery
50	50	network; and
51	51	(2) the usual charge for out-of-network health care
52	52	services.
53	53	SECTION 2. Subchapter A, Chapter 1301, Insurance Code, is
54	54	amended by adding Section 1301.010 to read as follows:
55	55	Sec. 1301.010. CALCULATION OF NONPREFERRED PROVIDER
56	56	PAYMENTS. (a) In this section, "usual charge for out-of-network
57	57	health care services" means the 99th percentile of the actual
58	58	charges charged by a nonpreferred provider for a particular health
59	59	care service in a particular service area covered by the preferred
60	60	provider benefit plan, as reported in a benchmarking database
61	61	maintained by a nonprofit organization that is not affiliated with
62	62	an insurer or other health benefit plan issuer, a holding company of
63	63	a health benefit plan issuer, or a trade association in the field of
64	64	insurance or health benefits.
65	65	(b) An insurer offering a preferred provider benefit plan
66	66	shall disclose to each insured and, if applicable, each group
67	67	policy holder the methodology used by the insurer to calculate
68	68	payment under the plan for health care services provided by
69	69	nonpreferred providers. The disclosure required by this section
70	70	must:
71	71	(1) express the payment amount in terms of a
72	72	percentage of the usual charge for out-of-network health care
73	73	services that will be paid to the provider; and
74	74	(2) include examples of the anticipated out-of-pocket
75	75	payment responsibility for frequently billed health care services
76	76	provided by nonpreferred providers.
77	77	(c) An insurer offering a preferred provider benefit plan
78	78	shall, at the request of an insured, provide the insured with
79	79	information, in writing or through publication on an Internet
80	80	website, that allows the insured to determine the anticipated
81	81	out-of-pocket payment responsibility for a specific health care
82	82	service provided by a nonpreferred provider based on:
83	83	(1) the methodology used by the insurer to calculate
84	84	payment under the plan for health care services provided by
85	85	nonpreferred providers; and
86	86	(2) the usual charge for out-of-network health care
87	87	services.
88	88	SECTION 3. The change in law made by this Act applies only
89	89	to a health plan contract or health insurance policy that is
90	90	delivered, issued for delivery, or renewed on or after January 1,
91	91	2014. A health plan contract or health insurance policy that is
92	92	delivered, issued for delivery, or renewed before January 1, 2014,
93	93	is covered by the law in effect immediately before the effective
94	94	date of this Act, and that law is continued in effect for that
95	95	purpose.
96	96	SECTION 4. This Act takes effect September 1, 2013.